How providers are failing mental health in-patients

The Care Quality Commission has highlighted poor practice among some mental health providers. Gordon Carson finds out where improvements can be made

There is consensus in the mental health sector that in-patient and community services have improved markedly over the past 10 years, but the Care Quality Commission’s annual report on the use of the Mental Health Act shows that poor practice continues to taint some in-patient services.

The CQC found that some providers were imposing blanket restrictions on detained in-patients, failing to assess or record patients’ consent to treatment and not involving patients in their care. These are at odds with the core principles set out in the act’s code of practice –  namely, respect, participation and removing restrictions.

Mark, who has been detained under the Mental Health Act for many years, says he has often felt his views have been ignored in planning his care.

“They [staff] have a two- or three-hour conference about you and you are given 10 minutes at the end to speak to them,” says Mark, a member of the CQC’s service user reference panel. “By then everybody has discussed you at length, answered all the questions themselves and made their mind up.”

Dr Tony Zigmond, the Royal College of Psychiatrists’ lead on mental health law and a psychiatrist in Leeds, says there is no excuse for providers failing to record patients’ consent to treatment.

“What tends to happen is that people will fill in the forms and do it well, but then not to record that they have assessed a patient’s capacity,” Zigmond says.

“We could look at this as a time and paperwork issue, but it’s more important than that. We need to constantly remind people that interviews with patients should be recorded.”

This could be said of all the issues highlighted by the CQC, but the realities of the pressures of frontline work may sometimes hamper consistent good practice.

Although there has been a decline in the past 10 years in the number of people treated as inpatients in mental health hospitals, the number detained in hospital for assessment or treatment has remained at about 45,000 a year.

There have been fewer admissions of patients with depression, learning disabilities or dementia, but admissions for schizophrenic and manic disorders have remained steady. In addition, 29% of acute wards visited by CQC commissioners in 2009-10 were over-occupied.

These issues may explain why some providers fail to meet standards. Simon Lawton-Smith, head of policy at the Mental Health Foundation, says: “Some of the problems arise from the fact that staff on wards are pressurised. They don’t have enough time to spend with patients.”

Individual staff may benefit from extra training that highlights the importance of engaging with patients, he says.

Meanwhile, Faye Wilson, deputy chair of the British Association of Social Workers’ mental health committee, says staff on inpatient wards may require more training on the Human Rights Act. She has worked in mental health services for 38 years, and has been employed in units that have imposed blanket policies stipulating that all doors must be locked. Blanket bans continue to exist, particularly on the use of mobile phones with in-built cameras.

Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust tackled this by offering in-patients the free use of phones without cameras, says chief operating officer Ian Jerams.

“There was one case where a person was taking multiple photos of other patients,” he says. “We took legal advice to make sure we struck a balance on human rights and weren’t depriving people of their right to keep essential contact with the outside world, but not exposing their fellow patients to some of the other risks.”

In addition to the challenges associated with managing patients with severe mental illnesses, mental health providers could also face greater funding and resource pressures in the next few years. Although the NHS has been awarded a 0.1% annual funding increase in real terms for the next four years, it must find £20bn efficiency savings.

Steve Shrubb, director of the NHS Confederation’s Mental Health Network, says there are also concerns over the ability of local authorities to maintain their contributions to mental health partnerships with the NHS, as they struggle to deal with cuts in central government funding.

However, the government has outlined plans to give local authorities a leadership role in its public health strategy, meaning social care models of working could have a greater influence in mental health services.

GPs will also need support from social services as they play a greater role in the commissioning of mental health services, says Wilson: “We need to commission for life outcomes, like social inclusion and employment, not just clinical outcomes.”

Contracts with providers may not make explicit statements on the use of blanket bans, for example. But, according to Shrubb, the best contracts will “make it clear that the subset of individuals who are under the [Mental Health] Act need to be treated in a particular way, and will lay down the values and principles. So when contracts are monitored, these issues become more apparent.”

The CQC will also maintain its monitoring of providers’ performance, and has the power to impose conditions on their registration if they fail to meet essential standards (see box).

But, as important as these sanctions are, the CQC would rather advise providers on improving their services before reaching this stage.

Nicola Vick, its policy lead on mental health, says initiatives such as the Star Wards scheme, which is led by service users, are particularly useful in sharing good practice among mental health service providers and staff.

“A lot of best practice is already there,” she adds. “The recommendations in the report are not about extra resources but about changes in practice.”

Case study: How Surrey and Borders turned round performance

Improved communication with staff, combined with a tough approach to confronting poor practice, helped to turn around performance at Surrey and Borders Partnership NHS Foundation Trust after the CQC imposed two conditions on its registration in April.

One of these insisted that, by 1 July, the trust properly assessed the capacity of patients to consent to their treatment and recorded the outcomes. It was notified of the CQC’s decision on 23 March and three days later it communicated to staff a new procedure to strive for 100% compliance.

“The key was for people to understand that it’s not just about form-filling and ticking boxes but it’s connected to human rights,” says Mandy Stevens, the trust’s director of quality and performance (nurse director).

The improvement strategy included weekly teleconferences between Stevens and associate directors, in which she scrutinised performance against the objective.

By early June, the trust was 97% compliant with the CQC’s condition that all people detained under the act were informed about their treatment, assessed on their capacity to consent to treatment, and that this was fully documented.

But this was not good enough for the Surrey and Borders board, which insisted on 100% compliance.

Stevens examined some files and found that the correct information was recorded in all cases, but had not always been completed within set timescales. So the trust introduced a new e-mail-based notification system for consultants, which culminated in a summons to a meeting with a medical director if they breached deadlines.

The CQC lifted the condition in September, after an audit of the files of 67 patients found Surrey and Borders had achieved 100% compliance.

Stevens will continue to monitor performance through quarterly internal audits. The second of these, scheduled for February, will include a qualitative element to find out how staff and patients feel about the consent process.

Related articles

CQC report

Star Wards

Mental Health Act code of practice

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